Fam Community Health Vol. 37, No. 4, pp. 258–270 C 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright 

Obesity and Perceived Severity of Obstructive Sleep Apnea–Related Conditions Matthew Lee Smith, PhD, MPH, CHES; Harold A. Smith, DDS; Kelly L. Wilson, PhD, MCHES; SangNam Ahn, PhD, MPSA; Jairus C. Pulczinski, BS; Marcia G. Ory, PhD, MPH This study examined risk factors and perceived severity of obstructive sleep apnea–related conditions among college students based on weight categories. Data collected from 1399 college students were analyzed using multinomial and binary logistic regressions. Overweight and obese participants were more likely to snore and report familial risk for cardiovascular disease compared with their normal weight counterparts. Relative to normal weight participants, obese participants perceived snoring (odds ratio [OR] = 1.10), irritability (OR = 1.16), and high blood pressure (OR = 1.21) as more severe; they perceived erectile dysfunction (OR = 0.89) and cardiovascular disease (OR = 0.71) as less severe. Efforts are needed to identify obstructive sleep apnea risk and create systems for weight loss interventions, screening, and diagnosis. Key words: obesity, obstructive sleep apnea, perceived risk, snoring, young adults

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BESITY is a major clinical correlate of obstructive sleep apnea (OSA),1-6 a condition in which individuals have labored breathing and temporary breathing cessation during sleep.1,2 While the obesity epidemic is widely recognized as a public health issue associated with chronic disease,7,8 it is not

Author Affiliations: Department of Health Promotion and Behavior, The University of Georgia College of Public, Health, Athens (Dr M. L. Smith); Department of Social and Behavioral Health, School of Public Health, Texas A&M Health Science Center, College Station (Drs Ahn and Ory and Mr Pulczinski); Dental Sleep Medicine of Indiana, Indianapolis (Dr H. A. Smith); Department of Health and Kinesiology, Texas A&M University, College Station (Dr Wilson); and Division of Health Systems Management and Policy, The University of Memphis School of Public Health, Memphis, Tennessee (Dr Ahn). The authors declare no conflict of interest. Correspondence: Matthew Lee Smith, PhD, MPH, CHES, Department of Health Promotion and Behavior, The University of Georgia College of Public Health, 330 River Rd, 315 Ramsey Center, Athens, GA 30602 ([email protected]). DOI: 10.1097/FCH.0000000000000042

surprising that obesity-related concerns and morbidities are predominant and steadily rising among the young adult population and on college campuses.9 Despite recognizing obesity as a root cause for chronic disease in middle-age and later life,2,8,10 young adults may not connect being overweight or obese with OSA or its related consequences. It is estimated that approximately 70% of adults with OSA are obese.5 Furthermore, familial risk factors such as a history of obesity and cardiovascular disease among parents and grandparents increases an individual’s risk for obesity and the likelihood that he or she will suffer from OSA-related conditions.11-14 Research indicates that family members of OSA patients have increased risk for OSA because of a genetic predisposition to the condition and shared lifestyle behaviors.14-16 To this end, it is important for young adults to inventory their family health history,17 assess their current health status and behaviors to evaluate their risk, and seek preventive action. Snoring is a sign and symptom of OSA, which indicates a narrowing of the airway

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Obesity and Perceived Severity of OSA-Related Conditions during sleep. Snoring is reported by almost 30% of college students, with a higher prevalence among males and those of certain ethnicities.18 Although many people view snoring as merely an annoying disturbance caused by vibrating tissue in the back of the throat, OSA has been linked to an array of serious health conditions, including high blood pressure, cardiovascular disease, stroke, irritability, decreased concentration, and erectile dysfunction.19,20 Unfortunately, young adults often discount the magnitude of their unhealthy behaviors and underestimate their risk for developing chronic disease,21 which can manifest as an unrealistic optimistic bias.22-25 College is a critical transition period that provides individuals with their first opportunity to make healthrelated decisions independent of their parents and establish lifelong behaviors.26 As such, their decisions about nutrition, physical activity, and alcohol consumption become increasingly important to prevent weight gain during the college years and offset future health conditions.27-30 However, an estimated 25% of young adults gain weight during their first year of college,29 which contributes to obesity and risks for other chronic conditions in later adulthood. Scant information exists about OSA among young adults; however, it is hypothesized to be underdiagnosed because of inadequate education and infrequent OSA screening among this potentially at-risk population. As such, understanding young adults’ perceptions about OSA risk factors and related conditions may be essential to predict future screening behavior and guide behavioral risk reduction interventions. Because OSA is strongly correlated with obesity, snoring, and family health history, further examination of these risk factors is warranted among younger aged adults. The purposes of this exploratory study were to: (1) identify young adults at risk for OSA based on their self-reported body mass index (BMI) and (2) examine differences in participants’ risk factors and perceived severity of OSArelated conditions based on their overweight or obese status. This study is among the first to

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examine risk and severity perceptions among young adults and may provide insight into target populations and content areas in which to educate about OSA-related risk and create OSA prevention interventions. METHODS Participants and procedures Data were collected from a sample of young adults enrolled in 2 large Texas universities, using Internet-delivered data collection methods in 2011. Participants were voluntarily recruited at each institution using electronic mail (e-mail) delivered via university-regulated delivery systems. After initial recruitment emails were sent, a reminder e-mail was distributed 5 days later. Approval for this study was independently received from each university’s institutional review board. Data were collected over a 2-week period at each institution. Of the 81 715 enrolled students who received the e-mail (ie, 49 129 and 32 586 at each institution, respectively), a total of 2054 students responded to the survey (response rate = 2.5%), with a total of 1639 completing the instrument (completion rate = 79.8%). Participants older than 30 years (n = 102), those with a BMI category of “underweight” (n = 87), and those who self-reported being diagnosed with OSA (n = 51) were omitted from these analyses, which yielded an analytic sample of 1399 cases. Instrument Participants were surveyed using a questionnaire consisting of 51 items. The instrument comprised a combination of Likert-type scales, close-ended response items, and openended response items. The instrument was designed by the researchers in accordance with clinical indicators contributing to and health outcomes associated with OSA.31,32 Items were also included to assess participants’ personal and familial risk factors (ie, independently associated with their mother and father) related to OSA. Participants took

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approximately 10 minutes to complete the survey instrument. Measures Dependent variable The dependent variable for this study was BMI, one of the strongest indicators of OSA. The BMI was calculated from participants’ self-reported height (in feet and inches) and weight (in pounds), which were converted to meters and kilograms, respectively. BMI levels were calculated by dividing weight by height and rounded to the nearest tenth.33 BMI categories were then created as follows: normal weight (BMI = 18.5-24.9 kg/m2 ), overweight (BMI = 25-29.9 kg/m2 ), and obese (BMI ≥30 kg/m2 ). Perceived severity of OSA-related conditions Participants were asked to independently rate how severe they considered 11 OSArelated conditions to be (ie, risk factors for, comorbidities with, or health outcomes of OSA). Participants were asked, “On a scale from 1 to 10, please rate how severe you think the following health issues are,” with 1 indicating “not severe at all” and 10 indicating “extremely severe.” The 11 health conditions included snoring, obesity, low sex drive, erectile dysfunction, decreased memory, decreased concentration, daytime sleepiness, irritability, depression, high blood pressure, and cardiovascular disease. Parental risk factors Participants were asked to provide healthrelated information about their mother and father. Participants were asked, “To the best of your knowledge, please indicate if your mother has ever been diagnosed with.” Conditions listed included obesity, high blood pressure, cardiovascular disease, and stroke. Response choices were “no,” “yes,” and “don’t know.” Responses for high blood pressure, cardiovascular disease, and stroke were combined and recoded to create a variable

indicating if their mother had ever been diagnosed with any cardiovascular disease–related condition (“no,” “yes,” and “don’t know”). Participants were asked to respond to the same items as they related to their father. Sociodemographics Personal characteristics of the participants included age (ie, continuous variable ranging from age 18 to 30 years), sex, and race/ethnicity (ie, non-Hispanic white, African American or black, Hispanic or Latino, Asian, or Pacific Islander). Participants were also asked if they had ever been told they snore (ie, “no,” “yes”). Statistical analyses All statistical analyses for this study were performed using SPSS (version 21). Frequencies were calculated for all major study variables that were initially examined in relationship to the respondent’s BMI category (ie, normal weight, overweight, and obese). Pearson χ 2 tests were performed to assess the independence between dependent variable and categorized independent variables. Oneway analyses of variance (F-statistics) were used to identify mean differences between BMI categories for continuous variables. Multinomial logistic regression was used to identify personal characteristics, personal risk factors, parental risk factors, and perceived severity of OSA-related conditions associated with participants’ BMI category (ie., normal weight served as the referent group). Logistic regression was performed to compare the personal characteristics, personal risk factors, parental risk factors, and perceived severity of OSA-related conditions associated with being obese (ie, overweight served as the referent group). RESULTS Sample Sample characteristics of study participants are presented in Table 1. Of the 1399 study participants, 60.7% (n = 849) were of normal

Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

187 (56.0) 99 (29.6) 48 (14.4)

376 (47.2) 421 (52.8) 716 (84.3) 101 (11.9) 32 (3.8)

521 (61.4) 236 (27.8) 92 (10.8)

You snore: No, n (%) You snore: Yes, n (%)

Mother diagnosed with obesity: No, n (%) Mother diagnosed with obesity: Yes, n (%) Mother diagnosed with obesity: Don’t know, n (%)

Mother diagnosed with cardiovascular disease: No, n (%) Mother diagnosed with cardiovascular disease: Yes, n (%) Mother diagnosed with cardiovascular disease: Don’t know, n (%)

241 (72.2) 64 (19.2) 29 (8.7)

110 (34.2) 212 (65.8)

210 (64.4) 19 (5.8) 75 (23.0) 22 (6.7)

595 (71.9) 29 (3.5) 144 (17.4) 60 (7.2)

Non-Hispanic white, n (%) African American or black, n (%) Hispanic or Latino, n (%) Asian or Pacific Islander, n (%)

152 (45.5) 182 (54.5)

21.45 (2.92)

Overweightb (n = 334)

254 (29.9) 595 (70.1)

20.71 (2.56)

Normal Weighta (n = 849)

Male, n (%) Female, n (%)

Age (18-30 y), mean (SD)

Table 1. Sample Characteristics by BMI Category

32 (14.8)

77 (35.6)

107 (49.5)

118 (54.6) 79 (36.6) 19 (8.8)

43 (21.0) 162 (79.0)

119 (57.2) 19 (9.1) 65 (31.3) 5 (2.4)

92 (42.6) 124 (57.4)

21.37 (2.82)

Obesec (n = 216)

172 (12.3)

412 (29.4)

815 (58.3)

1075 (76.8) 244 (17.4) 80 (5.7)

529 (40.0) 795 (60.0)

924 (67.8) 67 (4.9) 284 (20.9) 87 (6.4)

498 (35.6) 901 (64.4)

20.99 (2.71)

Total (N = 1399)

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Obesity and perceived severity of obstructive sleep apnea-related conditions.

This study examined risk factors and perceived severity of obstructive sleep apnea-related conditions among college students based on weight categorie...
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